Progression of Mesangial and Focal to Diffuse Lupus Nephritis

The finding of a focal glomerular lesion in systemic lupus erythematosus has been considered a good prognostic sign because the disease rarely progresses to a more severe histologic lesion and renal insufficiency. In 7.5 years, 110 of 165 such patients evaluated had clinical renal involvement, with biopsy in 69; 31 had a mesangial or focal lesion, 24 diffuse nephritis, and 14 membranous nephritis. The renal status of nine patients with an initial mesangial or focal lesion deteriorated one to 12 years later and progressed to diffuse nephritis. There was no difference between the groups with and without histologic progression in clinical severity of disease at the time of first biopsy, nor in the initial pattern of immunofluorescent or electron microscopical deposits within the glomerulus. It appears that mesangial, focal, and diffuse nephritis represent a continuum of increasingly advanced renal disease in systemic lupus erythematosus. In patients with systemic lupus erythematosus, the clinical course and ultimate outcome are frequently related to the severity of the associated renal disease. Recent publications have emphasized the finding of a “focal” glomerular lesion on the initial renal biopsy as indicating that the disease will rarely, if ever, progress to a diffuse proliferative lesion and renal insufficiency.^1,2 The implication of such a concept is that patients with a focal lesion (or less—a mesangial lesion) do not require treatment specifically for lupus nephritis. However, more recently, five patients with an initial mesangial or focal lesion have been described in whom the.